Cycle 1
Health 2025-08-27 · Fire 2025-08-27
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wellesley, MA
Elizabeth Seton
5-star overall rating with 5-star inspections
125 Oakland Street, Wellesley, MA
(781) 237-2161
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,149
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9940
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.72% · Performance 21.91% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.48
Baseline 4.60% · Performance 7.39% · Measure score 1.48 · Achievement 1.48 · Improvement 0
Total nurse turnover
10
Baseline 36.00% · Performance 22.97% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
4.96
Baseline 4.66 hours · Performance 4.49 hours · Measure score 4.96 · Achievement 4.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.32% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 430 · Observed rate 7.44% · Lower 95% interval 7.55% |
| Discharge to community | 62.55% |
50.57%
12 pts better
|
Better than the National Rate · Eligible stays 458 · Observed rate 62.88% · Lower 95% interval 58.66% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 86.79% |
95.27%
8.5 pts worse
|
Numerator 243 · Denominator 280 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 280 |
| Discharge self-care score | 48.28% |
53.69%
5.4 pts worse
|
Numerator 112 · Denominator 232 |
| Discharge mobility score | 56.9% |
50.94%
6 pts better
|
Numerator 132 · Denominator 232 |
| Pressure ulcers or injuries, new or worsened | 0.36% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 280 · Adjusted rate 0.45% |
| Healthcare-associated infections requiring hospitalization | 7.39% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 282 · Observed rate 6.03% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 14.29% |
8.2%
6.1 pts better
|
Numerator 19 · Denominator 133 |
| Staff flu vaccination coverage | 50.78% |
42%
8.8 pts better
|
Numerator 98 · Denominator 193 |
| Discharge function score | 57.76% |
56.45%
1.3 pts better
|
Numerator 134 · Denominator 232 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 42 · Denominator 42 |
| Transfer of health information to patient | 99.01% |
96.28%
2.7 pts better
|
Numerator 201 · Denominator 203 |
| Resident COVID-19 vaccinations up to date | 45.45% |
25.2%
20.3 pts better
|
Numerator 60 · Denominator 132 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.9
0.9 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.4% |
92.2%
8.8 pts worse
|
93.4%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 93.2% · Q3 61.9% · Q4 88.1% · 4Q avg 83.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.0% |
94.8%
3.8 pts worse
|
95.5%
4.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.5%
1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 1.6% · Q4 3.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.2%
About the same
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.3% · Q3 5.9% · Q4 8.7% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
19.2%
11.6 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 7.8% · Q3 7.8% · Q4 8.7% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
22.5%
13 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 8.8% · Q3 8.9% · Q4 6.7% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.7% |
17.7%
19 pts worse
|
16.3%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 26.8% · Q3 52.2% · Q4 29.6% · 4Q avg 36.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
17.6%
4.1 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 12.2% · Q3 36.7% · Q4 23.9% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.0%
0.4 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.3% · Q4 2.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
2.0%
3.5 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.5% · Q3 9.5% · Q4 6.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
21.7%
5.3 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 26.1% · Q3 41.3% · Q4 19.3% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.6%
1.5 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.9% · Q3 3.1% · Q4 5.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.3% |
77.1%
7.2 pts better
|
81.7%
2.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.2% · Q2 73.3% · Q3 86.4% · Q4 98.2% · 4Q avg 84.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
11.8%
0.7 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 9.5% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.9% |
77.7%
0.2 pts better
|
79.7%
1.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
25.8%
1 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 19.8% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-04 · Fire 2024-09-04
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-08-31 · Fire 2023-08-31
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-30
B · Minimal harm
2024-09-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-30
E · Potential for more than minimal harm
2023-08-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-31
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-28
Penalties and ownership
What sits behind the stars
Ownership
Ferrante, Lori
Operational/Managerial Control · Individual
Ferrante, Lori
Corporate Director · Individual
O'keefe, Joan
Corporate Officer · Individual
Nearby options
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#3
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